Chronic Obstructive Pulmonary Disease

(COPD)______________________________

Aminu ArzetDepartment of Internal Medicine

Nelson Mandela School of MedicineUniversity of K-Natal

Durban

27th March,2015

ICU 2B/Respiratory unit presentation

Inkosi Albert Luthuli Central Hospital (IALCH)

DURBAN

Introduction

COPD Is a lung disease characterized by persistent, progressive airway obstruction, that leads to poor airflow in and out of lungs, with resultantreduction in FEV1and FEV1/FVC ratio.

The lung function impairment is fixed, but some reversibility can be achieved by using bronchodilator/other therapies

Introduction Continuation

Its associated with shortness of breath, cough, and sputum production, which is due to chronic inflammatory response in the airways and lungs to noxious substances.

It commonly involve narrowing of small airways(small airway disease) and breakdown of lung tissue,with resultant entrapment of air (emphysema).

Epidemiology

COPD is a leading course of morbidity and mortality world over

It affects about 5% of world population (330 million people)

In 2012, it ranked as the 3rd leading cause of death, killing over 3 million people globally.

Epidemiology Continuation

The number of deaths is projected to increase due to higher smoking rates and an aging population globally.

It resulted in an estimated economic lost of about $2.1 trillion across the globe in 2010 .

Risk FactorsCigarette smoking is the major risk factor for COPD

Occupational exposure to dust and chemicals

Environmental pollution from Car exhaust, tobacco smoke, wild fire/bush burning, poorly ventilated indoor cooking fires using biomass fuel(BMF).

Risk factor continuation

Genetic makeup of individual- Alpha1 antitrypsin deficiency

Recurrent bronchopulmonary infections

Socioeconomic status-commoner among less privileged.

Pathophysiology

Air ways obstruction occur as a result of chronic inflammatory response to inhaled noxious substances and recurrent infection.

There is excessive release of inflammatory mediators like Nuetrophils, Macrophages, Lymphocytes, Histamines, Leukotrienes, Cytokines,Chemokines, free radicals,etc

Pathophysiology Cont.

The irritation causes mucus gland to become thickened, blocking the air way, at same time producing excessive mucus secretion, which clog the airways the more

Inflammation/fibrosis of small airways due to recurrent infection/Irritation is termed as small airway disease, and this give rise to air flow limitation

Pathophysiology Cont.

Alveolar wall destruction due to breakage of alveolar attachment, and lost of elasticity with resultant decrease in elastic recoil, are another cause of air entrapment, and emphysema ensued.

In addition to aforementioned, Pulmonary capillary bed damage and attendant pulmonary edema, amplify the airflow limitation.

Pathophysiology Cont.Lung damage also occur due to break down of lung tissue by inflammatory cells and released proteases, which are insufficiently inhibited, due to lack of Alpha1antitrypsin(anti protease).

Alpha1antrypsin deficiency is genetically mediated, but cigarette smoking is believed to potentiate that, by stimulating release of free radicals and inflammatory cells.

Clinical features Symptoms: Include shortness of

breath, cough, sputum production, dyspnoea, and wheeze.

Signs:

Pink puffers-Thin body build, with expiratory pursed -lip breathing

Blue bloaters–cyanosis with mild activity

Clinical features Patients

Patient who have chronic cough and sputum production with a history of exposure to risk factors, should be tested for airflow limitation, even if they do not have dyspnea .

Physical examination Pt has large, barrel shaped chest,

Prominent accessory respiratory muscles in the neck.

Low, flat diaphragm, causing costal margin retractions on inspiration.

Hyperimplated lungs with diminished breath sounds, distant HS, prolonged expiration with generalized wheezes predominantly on expiration.

Physical examinations cont

Depressed liver, which is not enlarged.

In ‘blue bloater’ type of COPD, patient may also have:

Cyanosis at rest or mild exertion.Pedal oedemaCrackles at lung bases.Loud second heart sound in pulmonary area (difficult to hear in COPD).

Physical examinations cont

In ‘pink puffer’ type of COPD patient may also have:

expiratory pursed-lip breathing, thin body build and tendency to lean forward over a support to assist breathing

Investigations

Plain chest X-ray shows

1. Low flattened diaphragms.

2. An obtuse costophrenic angle.

4. A reduction in size and numbers of pulmonary vessels, particularly in the periphery of the lung.

5. Vessel distortion producing increased branching, angles or bowing of vessels

CT CHEST It shows areas of low attenuation

without obvious margins or walls.

Abnormal vascular configuration.

CT Scan is the most sensitive and specific imaging technique for assessing Emphysema

Diagnosis Clinically based on dyspnoea,

Chronic cough and exposure to risk factors.

Spirometry is the gold standard.

Post bronchodilator FEV1/FVC < 70% or FEV1 < 80% of predicted value, confirms the presence of airflow limitation that is not fully reversible.

Spirometry:Decreased FEV1, FEV1/FVC,

Lung volumes:Increased Total Lung CapacityIncreased Residual VolumeIncreased RV/TLC

Additional investigations

1.Bronchodilator reversibility testing

2. Glucocorticosteroid reversibility testing

3. Arterial blood gas measurement

4. Alpha1 antitrypsin deficiency screening

Additional investigations cont.

Alpha 1 antitrypsin screening is done in the fallowing settings:

- COPD develops under 45

- COPD develops in non-smoker

- Strong family history of COPD

Normal: >150 mg/dL , In disease: <45 mg/dL

Differential diagnosis

Asthma-due to bronchoconstriction

Congestive Heart Failure

Bronchiectasis

Tuberculosis

Obliterative Bronchiolitis

Management

First is to determine the severity of the disease, and total health condition of the patient.

Consider the following aspects of the disease separately:

current level of patient’s symptoms severity of the spirometric abnormality frequency of exacerbations

presence of comorbidities.

Symptoms assessment

COPD symptoms are chronic and progressive dyspnea, cough, and sputum production that can vary from day to day.

In symptoms assessment these features are objectively graded using the fallowing scoring systems:

Stmptoms assesement cont.

1. COPD Assessment Test (CAT): An 8 items measure of health status impairment in COPD

2. Clinical COPD Questionnaire (CCQ): This is self administered questionnaire, developed to measure clinical control in patients with COPD.

Symptoms assesement cont

3. Modified British Medical Research Council(mMRC) Questionnaire: It also assesses health status and predicts future mortality risk. It has a score of 0-4

Two or more exacerbations within the last year

One or more Hospitalization for a COPD exacerbation

FEV1 < 50 % of predicted value are indicators of high risk patient.

Stage Characteristics Recommended Treatment

All * Avoidance of risk factor (s)

* Influenza vaccination

0: At risk * Chronic Symptoms

(cough, Sputum)

* Exposure to risk factors

* Normal spirometry

Mild COPD * FEV1/FVC < 70% *Short acting B/dilator

* FEV1 80% predicted when needed or SAMA

* With or without symptoms

Therapy at Each Stage of COPD

Stage Characteristics Recommended Treatment

Moderate FEV1 50 -79% *Regular treatment * Inhaled Gluccocorti COPDD with one or more costeorodis +

bronchodilators LABA or LAMA

* Rehabilitation Symptoms and lung

function response

Therapy at Each Stage of COPD

Stage Characteristics Recommended Treatment

Severe COPD FEV1 30-49% * Regular treatment with LABA+

and or LAMA

Very Severe FEV1<30% * Inhaled glucorticosteroids if

COPD significant symptoms or repeated

exacerbations.

* Treatment of complications.

* Consider surgical treatments -

lung volume reduction /transplant

* Long-term oxygen therapy if

in respiratory failure

* Rehabilitation- exercise,

*Health Education-cessation of smoking

COPD Comorbidities

COPD patients are at increased risk for:

CVS disease like Corpulmonale

Osteoporosis

Respiratory infections

Anxiety and Depression

Diabetes

Lung cancer

Bronchiectasis

Prognosis

Prognosis is generally poor, unless if detected early and management start

in early stage.

THANK YOU

Reference

•GOLD 2014/2006 document

•Kumar and ckerk

•Harrison

•Davidsons

•British medical journal

•Wikipedia